Update: Acceptable Image Formats from Digital Radiography Systems (computed or direct digital radiography) at Panel Physician Sites

May 2012

This document updates a 2008 posting on technical information about image formats acceptable to CDC from digital radiography systems (computed or direct digital radiography) at panel physician sites using the 1991 Technical Instructions (TI) or the Culture and DOT (formerly the 2007) Tuberculosis TI.

All refugees, immigrants, and other applicants who have a chest image obtained during medical screening overseas must bring a copy of that image into the United States. The chest image is used by receiving U.S. health departments in the follow-up evaluation for tuberculosis (TB) infection and disease. For panel sites with digital radiography systems (computed or direct digital radiography), a recordable compact disk (CD-R) can be substituted for a laser-printed film, if the image burned onto the CD-R is DICOM-standard* and in a noncompressed format.

For panel physicians with digital radiography systems:

• Each applicant who has had a digital chest radiograph overseas, even an applicant with no TB classification, must bring the image into the United States. Either a chest CD-R or a laser-printed chest film may be used. The laser-printed image must be 100% in size.
• If the applicant has a Class A TB or Class B1 TB condition (or Class B2 TB condition if the 1991 TI are used), the panel physician should receive the CD-R directly from the radiology facility; the image should not be transported by the applicant.
• The image(s) burned onto the CD-R must be DICOM-standard and noncompressed. An average noncompressed chest image contains 8-10 MB of raw data. Rewritable (CD-RW) CDs are not acceptable.
• Each CD-R must contain only one applicant’s image(s). Images of more than one family member should not be burned onto the same CD-R.
• Each CD-R should also contain a viewer to access and optimize the image(s).
• Other image requirements still apply (e.g., clearly marked applicant name, facility name, and date of image exposure; appropriate technique, positioning, and inspiration).
• The CD-R should be placed in an envelope (or jewel case). The CD-R and the envelope should be marked with the applicant’s name, the facility name, and the date of image exposure. The envelope must fully enclose the CD-R and be sealed.
• The CD-R envelope should be given to the applicant with instructions to bring it into the United States and to keep it secure, so that it will be available for any follow-up evaluation. To avoid loss of the CD-R image(s) to Customs and Border Protection (CBP) at the port of entry, the CD-R envelope should NOT be stapled to the applicant’s DS forms or other paperwork and should NOT be given to CBP.
• CD-Rs with raw data are superior to static radiographs (laser-printed films) because raw data can be optimized (e.g., contrast adjusted, magnified) by the interpreter. However, a laser-printed film is acceptable if the chest image cannot be burned onto a CD.

For receiving U.S. health departments:

• CD-Rs can be viewed in health departments or offices with analog (conventional film-screen) radiography systems or no radiography systems (see below)
• Many CD-R images are accompanied by a "viewer," which allows the receiver to open and optimize the raw data of the image. If no viewer accompanies the image or if the accompanying viewer doesn't function on a particular computer, the receiver can download and use other viewers, such as ImageJ, a public domain Java image processing and analysis program found at http://rsb.info.nih.gov/ij/. ImageJ runs, either as an online applet or as a downloadable application, on any computer with a Java 1.5 or later virtual machine. Downloadable versions are available for Windows, Mac OS X, and Linux.
• High-resolution monitors provide optimal viewing of CD-R images but are costly. As images obtained overseas have already been officially interpreted, they can be viewed for comparison on personal computers, if needed.

*Digital Imaging and Communication in Medicine